Dose of dialysis: Key lessons from major observational studies and clinical trials

Saran, Rajiv; Canaud, Bernard; Depner, Thomas A.; Keen, Marcia L.; McCullough, Keith; Marshall, Mark R.; Port, Friedrich K.

doi:10.1053/j.ajkd.2004.08.011

Cited by 19 publications

(13 citation statements)

References 22 publications

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“…These results contrast markedly with observational studies that have consistently shown associations between higher dialysis dose and survival (3)(4)(5). In a previous analysis of HEMO Study data, we found strong associations between the achieved dose and survival within each of the two randomized dose groups (6).…”

Section: Introductioncontrasting

confidence: 55%

Modeled Urea Distribution Volume and Mortality in the HEMO Study

Daugirdas

Greene

Depner

et al. 2011

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives In the Hemodialysis (HEMO) Study, observed small decreases in achieved equilibrated Kt/V urea were noncausally associated with markedly increased mortality. Here we examine the association of mortality with modeled volume (V m ), the denominator of equilibrated Kt/V urea .Design, setting, participants, & measurements Parameters derived from modeled urea kinetics (including V m ) and blood pressure (BP) were obtained monthly in 1846 patients. Case mix-adjusted time-dependent Cox regressions were used to relate the relative mortality hazard at each time point to V m and to the change in V m over the preceding 6 months. Mixed effects models were used to relate V m to changes in intradialytic systolic BP and to other factors at each follow-up visit.Results Mortality was associated with V m and change in V m over the preceding 6 months. The association between change in V m and mortality was independent of vascular access complications. In contrast, mortality was inversely associated with V calculated from anthropometric measurements (V ant ). In case mix-adjusted analysis using V m as a time-dependent covariate, the association of mortality with V m strengthened after statistical adjustment for V ant . After adjustment for V ant , higher V m was associated with slightly smaller reductions in intradialytic systolic BP and with risk factors for mortality including recent hospitalization and reductions in serum albumin concentration and body weight. ConclusionsAn increase in V m is a marker for illness and mortality risk in hemodialysis patients.

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Section: Introductioncontrasting

confidence: 55%

Modeled Urea Distribution Volume and Mortality in the HEMO Study

Daugirdas

Greene

Depner

et al. 2011

Clinical Journal of the American Society of Nephrology

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“…4 In the literature to date, there have been conflicting reports on the effects of dialysis dose on patient QOL and outcomes. Although several analyses of registry data have suggested favorable outcomes, 5 the HEMO study found that overall QOL was not improved by dialysis dose or high-flux membranes. Small improvements in physical functioning and pain were reported.…”

Section: Introductionmentioning

confidence: 98%

Quality of life and alternate nightly nocturnal home hemodialysis

Eps

Jeffries²,

Johnson

et al. 2010

Hemodialysis International

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Hemodialysis has been associated with reduced quality of life (QOL). Small cohort studies of quotidian hemodialysis regimens suggest general QOL and dialysis-related symptoms may improve compared with conventional regimens. An observational cohort study was conducted on 63 patients (age 51.7 +/- 12.9 years; 79.4% male; 33.3% diabetes; duration of renal replacement therapy 1.9 [0.7-6.4] years) converted from conventional home hemodialysis (3-5 sessions weekly, 3-6 h/session) to home nocturnal home hemodialysis (NHD) (3-5 sessions weekly, 6-10 h/session). Kidney Disease Quality of Life (KDQOL) and Assessment of Quality of Life instruments and 6-minute-walk tests were applied at baseline and 6 months. Baseline and 6 month surveys were returned by 70% of patients. On KDQOL, significant improvements in general health (P=0.02) and overall health ratings (P=0.0008), physical function (P=0.003), physical role (P=0.018), and energy and fatigue (P=0.027) were documented. There was a trend toward improvement in burden of kidney disease (P=0.05) and emotional role (P=0.066). There was a significant improvement in distance covered in the 6-minute-walk test from 513 m (420.5-576.4) to 536.5 m (459-609), P=0.007. On Assessment of Quality of Life, there was a trend toward improvement in overall utility score from 0.65 (0.39-0.81) to 0.73 (0.46-0.86), P=0.096. After 86.2 patient-years of observation, 23 patients have discontinued NHD (12 transplanted, 5 deceased, 4 psychosocial problems, 1 dialysis access problem, 1 medically unsuitable). Nocturnal home hemodialysis is a sustainable therapy. In addition to improving general QOL, alternate nightly NHD can significantly improve physical functioning as measured by KDQOL and 6-minute-walk tests.

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“…Longer TT was associated with lower mortality in Japan (HR ¼ 0.75 per 30 min longer TT) and in European countries, Australia, and New Zealand (HR 0.94 per 30 min longer TT). 2 The study by Saran et al 33 using the DOPPS database and more recently by Flythe et al 34 using the database of a large dialysis provider have both shown that the UFR has a significant impact on HD mortality rate: UFR 410 ml/kg/h is associated with increased all-cause and cardiovascular mortality, possibly on the basis of cardiac stunning, subclinical cardiac ischemia, and hemodynamic instability during rapid ultrafiltration. Subsequently, Flythe et al 34 reported on the association between TT and survival, and found a substantial mortality increase associated with a dialysis session of o4 h, even when adjusted for body size (Figure 2).…”

Section: What Should the Minimum Dialysis Session Length Be?mentioning

confidence: 99%

Dialysis frequency versus dialysis time, that is the question

Hakim

Saha

2014

Kidney International

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We reviewed a number of prospective randomized and multiple retrospective cohort studies of different dialysis prescriptions: longer dialysis time, at a frequency of at least three times a week, or a frequency of daily hemodialysis with a shorter dialysis time. Interestingly, the retrospective analyses have generally found significant survival benefits in the intensive dialysis groups, whereas more modest effects were observed in the prospective randomized controlled trials. The reason for this discrepancy may be related to the retrospective nature of the studies and possible selection bias; for example, the patients who were prescribed more frequent dialysis may have had more difficulties with volume control or high blood pressure. In contrast, the randomized controlled trials of increased dialysis frequency, which have shown indirect and modest benefits in complex coprimary end points, have small sample sizes and are plagued with difficulties in recruitment and compliance with the randomly allocated more frequent dialysis. This review, which attempts to balance the potential benefits of more frequent dialysis with the burden on the patient's lifestyle, an increased risk of access malfunction, as well as societal costs of such intensive dialysis prescriptions, concludes in favor of the conventional three times per week dialysis (at a minimum) but at longer dialysis times than is currently prescribed based on the Kt/Vurea metric alone.

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Dose of dialysis: Key lessons from major observational studies and clinical trials

Cited by 19 publications

References 22 publications

Modeled Urea Distribution Volume and Mortality in the HEMO Study

Modeled Urea Distribution Volume and Mortality in the HEMO Study

Quality of life and alternate nightly nocturnal home hemodialysis

Dialysis frequency versus dialysis time, that is the question

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